P375: CHALLENGES IN MANAGEMENT OF ACUTE LYMPHOBLASTIC LEUKAEMIA IN A RESOURCE CONSTRAINED SETTING IN LOWER-MIDDLE-INCOME COUNTRIES (LMICS)
Authors: T. Vaid, R. Dhawan, M. Aggarwal, P. Kumar, J. Dass, G. VIswanathan, T. Seth, S. Tyagi, M. Mahapatra
Journal: HemaSphere (2022)

Background: Improvement in supportive care, introduction of more intensive chemotherapy regimens and strategic use of allogenic stem cell transplant in some patients has resulted in significant improvement in outcomes of patients with acute lymphoblastic leukemia (ALL). However, this improvement is largely restricted to the developed world. We explore these challenges encountered in treating ALL in one of the largest government hospitals in India. Aims: This study aims to assess the baseline characteristics, outcomes and challenges in management of acute lymphoblastic leukaemia in a resource constrained setting in lower-middle-income countries (LMICs) Methods: Consecutive patients diagnosed with acute lymphoblastic leukaemia in the department of Hematology from 1 January 2017 to 31 December 2019 were included. Pediatric patients were treated with standard or augmented BFM protocols depending on risk stratification. Adolescent and yound adults (AYA) were treated with pediatric inspired protocols or GMALL like protocols. Adult patients were treated with GMALL like protocol. Results: Of the 273 patients diagnosed with ALL, only 197 (72%) were able to get admitted for treatment at our institute. Median time from diagnosis to admission was 12.5 days (range: 0 -190 days) and the median distance of the patient’s permanent residence and our institute was 217 km (range 3-2400km). Baseline characteristics of these 197 patients are mentioned in Table 1. Of the 197 patients treated at our centre, only 165 (83.7%) were able to receive induction chemotherapy. Of the remaining 32 patients, 26 (13.2%) died before treatment could be initiated and 6 (3%) were lost to follow up. Patients who died prior to starting chemotherapy had significantly higher incidence of baseline infection and organ dysfunction compared to those receiving induction. Neutropenic fever was present in 50.56% patients at the time of admission. Focus of infection was lungs in 68.5%, sinusitis in 6.8%, skin & soft tissues in 5.6%, neutropenic enterocolitis in 2.2%, pyelonephritis in 1.1%, splenic abscess in 1.1% & bacteraemia with no obvious focus in 14.7% patients. 58.6% of the patients developed a new episode of neutropenic fever during induction chemotherapy. Post induction, a cumulative of 70 episodes of neutropenic fever and other infections were noted in 57 patients, of these 19 patients needed hospitalization. At the end of induction, 64.5% (n=127) patients achieved complete remission. Induction mortality was 27.9% (n=55) and 4.1% (n=8) patients were lost to follow up. Primary refractory disease was noted in 3.5% (n=7) patients. After a follow up period of 4 years, only 22.8% (n=45) patients were alive and on regular therapy, 32% (n=63) patients died & 25.4% (n=50) patients were lost to follow up. CNS relapse & medullary relapse was noted in 7.1% (n=14) & 9.1% (n=18) patients respectively. 4-year event free survival was 57% for both standard risk and high risk paediatric ALL patients respectively, 44% & 35% for standard risk and high risk AYA patients respectively & 20% and 27% for standard risk and high-risk adult ALL patients. Image:Summary/Conclusion: ALL patients in our study had a high incidence of infection and organ dysfunction at baseline that complicated therapy. With limited access to healthcare, poor socio-economic status and high incidence of infection, developing countries face a unique set of challenges. Outcomes of ALL patients in our cohort are at odds with those reported from the developed world.